65 Title 5 Upgrade Application/Repair Instructions 2003 ENVIRONMENTAL FIELD SERVICES, INC.
P.O. BOX 518
LEEDS, MA 01053 1-413-586-7200
Address of property 6,
Owner's name h/«rc 1VIOarC
Date of Inspection ?S _ 9S-
PART A
CHECKLIST
SEPTIC
SYSTEM
INSPECTION
C Vs)c i-e ✓'CC
i
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
Health.
V. None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
✓ As built plans have been obtained and examined. Note if they are not
available with N/A.
• The facility or dwelling was inspected for signs of sewage back-up.
/ The site was inspected for signs of breakout.
VAll system components, excluding the SAS, have been located on the
site.
✓ The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
✓ The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
V7 The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
ENVIRONMENTAL FIELD SERVICES, INC. SEPTIC
P.O. BOX 518 SYSTEM
LEEDS, MA 01053 1-413-586-7200 INSPECTION
FLOW CONDITIONS
If residential
3 number of bedrooms
`1 number of current residents
r.° garbage grinder, yes or no
y c laundry connected to system, yes or no
E. n seasonal use, yes or no
If nonresidential, calculated flow:
water meter readings, if available:
S 4v-1-u.I Last date of occupancy
GENERAL INFORMATION
Pumping records and source of infprmation:
S - /8 - 4s
IVZ System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
Type of system
✓ Septic tank/distribution box/soil absorption system
Single cesspool
_ Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection
records, if any)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
PLO Sewage odors detected when arriving at the site, yes or no
ENVIRONMENTAL FIELD SERVICES, INC. SEPTIC
P.O. BOX 518 SYSTEM
LEEDS MA 01053 1-413-586-7200 INSPECTION
SEPTIC TANK:
(locate on site plan)
depth below grade: c77
material of construction: ✓concrete _metal _FRP _other(explain)
dimensions: /O X S ,K Et,
N/b
sludge depth
distance from top of
scum thickness
distance from top of
distance from bottom
sludge to bottom of outlet tee or baffle
scum to top of outlet tee or baffle
of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
+
DISTRIBUTION BOX: V`
(locate on site plan)
0 depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
lr, c cacC CVtn4 C< 0,0A4'-
PUM'Py,,.�',',•sE'R:
( alb to on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
ENVIRONMENTAL FIELD SERVICES, INC.
AO. BOX 518
LEEDS, MA 01053 1-413-586-7200
SEPTIC
SYSTEM
INSPECTION
SOIL ABSORPTION SYSTEM (SAS) : Y
(locate on site plan, if possible: excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type
leaching
leaching
leaching
leaching
leaching
overflow
pits and number
chambers and number
galleries and number
trenches, number, length
fields, number, dimensions
cesspool, number
(l j>/)J-a X. .7-riot- .
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
c3SBP6LS (locate on site plan) :
number and configuration
depth-top of liquid to inlet invert
depth of solids layer
depth of scum layer
dimensions of cesspool
materials of construction
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
P Y:
(locate on site plan)
materials of construction
dimensions
depth of solids
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
ENVIRONMENTAL FIELD SERVICES, INC. SEPTIC
P.O. BOX 518 SYSTEM
LEEDS, MA 07053 1-413-586-7200 INSPECTION
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
D -6o r
riuLc r
u '
- /ec.c Z/' e ld
E
S /, es-
/ear-I
Pit
/Aim c
' to w ern
72i n C ae-
n.q
c(c 7) ,-' ve
DEPTH TO GROUNDWATER
JO depth to groundwater
method of determination or approximation:
n e✓er A i+( ct fry fl pw>%a / s.ever °c/oo de
riur'ag y e / C7,0 •0.9 •
cxrCyn /- Dint
ENVIRONMENTAL FIELD SERVICES, INC. SEPTIC
P.O. BOX 518 SYSTEM
LEEDS, MA 01053 1-413-586-7200 INSPECTION
indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
'1/ Backup of sewage into facility?
A/ Discharge or ponding of effluent to the surface of the ground or
surface waters?
Al Static liquid level in the distribution box above outlet invert?
mip Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
Required pumping 4 times or more in the last year?
number of times pumped /
M Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
/J below the high groundwater elevation?
N within 50 feet of a surface water?
Al within 100 feet of a surface water supply or tributary to a surface
water supply?
Ai within a Zone I of a public well?
Oa within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
_!IL within 50 feet of a private water supply well?
A/ less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analys
for conform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
ENVIRONMENTAL FIELD SERVICES, INC. SEPTIC
P.O. BOX 518 SYSTEM
LEEDS, MA 01053 1-413-586-7200 INSPECTION
Name of Inspector /72. c tae /Pi/fa^e
Company Name
C0- 1jo✓C/
Company Address
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Che k one:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303. Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
_ I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15.303. The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector's Signature
Date g_ L/ _ 1S"'
Original to system owner
Copies to:
Buyer (if applicable)
Approving authority
Environmental Field Services
P.O. Box 518 Leeds, MA
586-7200
Repair Instructions for Septic System
65 Momingside Drive, Florence, MA
Existing
3 Br.
Home
Deck
Septic — cfs
Teak
Leach Field
Leach Pit O
Approximate Property Line
Construction Notes:
1.) Septic Tank requires the installation of an outlet Tee(310 CMR 15.227)to replace the
broken outlet baffle. Tee to be 4" diameter PVC SDR 35 (or equivalent)and must extend
approximately 19"below the outlet invert.
2.) All pipe between the septic tank and the D-box to be removed and replaced with 4"diameter
PVC SDR 35 (or equivalent). Two 45 degree bends shall replace the cast 90 degree elbow.
3.) The D-box sump is to be cleaned thoroughly of all solids and,to the extent possible without
disturbing the box or the leach lines,the five exit pipes shall be cleaned of any solids lining
their bottoms for the first five to ten feet as practical.
4.) The Board of Health and the Engineer must be notified to inspect the repairs prior to closure.
FORM 9A - Application for Local Upgrade Approval
Commonwealth of Massachusetts
MotiNAtte —o n) ,Massachusetts
(City/Town)
Application for LOCAL UPGRADE APPROVAL
Title 5, 310 CMR 15.000
DEP Approved Form Required by 310 CMR 15.403(1)
Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or
nonconforming septic system with a design flow of less than 10,000 gpd,where full compliance,as
defined in 310 CMR 15.404(1), is not feasible.
System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405,or in full
compliance with the requirements of 310 CMR 15.000,require a variance pursuant to 310 CMR
15.410 through 15.417.
NOTE:Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of a
new design flow to a cesspool or privy,or the addition of a new design flow above the existing approved
capacity of a septic system constructed in accordance with either the 1978 Code or 310 CMR 15.000.
Facility Address:g.S:,67nPano-A C/hr bt City/Town: /JOe&N, nk3 ..)
Facility/System owner:.Sas.A) XAP_af 9-1 2ntA/R • +iC1vn16,e efl)
Address: (,,f/H APitly1LS1.bf t/G
City/Town: AJOaLTNHaeATne-, State: fr/H Zip: O/o60
Telephone: ( '7/ ) SRL 221 j
Type of Facility(check all that apply): ®Resr'*ntial ❑Institutional ❑Commercial ❑School
Describe facility `ii3GLeccM MMMCCIA]6/ N.0770VE /..qPy .£lnEiAIDC,�
Type of existing system: ❑Privy ❑Cesspool(s) 0Conventional System
❑Other(describe)
Type of soil absorption system (trenches,chambers,leach field,pits,etc)
Design Flow per 310 CMR 15.203:
Design flow of existing system UA1hAbu3N gpd
Design flow of proposed upgraded system <SO. T gpd
Design flow of facility YYO gpd
Proposed upgrade of system is: Cif Voluntary ❑Required by order, letter,etc.(attach copy)
❑ Required following inspection pursuant to 310 CMR 15.301
Provide date of inspection / /
Deparunent of Environmental Protection
FORM 9A - Application for Local Upgrade Approval
Page 1 of3
DEP Approved Forth-3/20/02
Describe the proposed upgrade to the system
/WO 1.64cMa06 FACtr_1-ry, CaP$rtQ6Pu1Tv2 mr1<rNE '/mount.
Local Upgrade Approval is requested for:
❑ Reduction in setback(s) (Describe reductions)
❑ Percolation rate for 30 to 60 min/inch Percolation rate min/inch
❑ Reduction in SAS area of up to 25%
(SAS size and%reduction) SAS sq fl Reduction %
• Reduction in separation between the SAS and high groundwater
Separation reduction r/—,4 ft Percolation rate .20 min/inch
Depth to groundwater 3, C ft
❑ Relocation of water supply well(Explain)
❑ Other requirements of 310 CMR 15.000 that cannot be met
Describe and specify sections of the Code
If the proposed upgrade involves a reduction in the required separation between the bottom of the soil
absorption system and the high groundwater elevation,an Approved Soil Evaluator must determine the
high groundwater elevation pursuant to 310 CMR 15.405(1)(iX1).The soil evaluator must be a member
or anent of the local anoroving authority.
High groundwater elevation determined by:
&TFP /le14411.5
(Print or type evaluator's Name) (Signature of evaluator) (Evaluation Date)
Explain why full compliance,as defined in 310 CMR 15.404(1),is not feasible.
(Each section must be completed)
1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible: c/R/(ZDM[b .<1fir.PA7"rd 0
U.ffTZP bgl.UT t Tu rcla r/
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
FktT FFAS uT(_
Li
Department of Environmental Protection
Page 2 of 3
DEP Approved Fonn-3/20102
FORM 9A - Application for Local Upgrade Approval
3. A shared system is not feasible: Aim 0 O 'TO.SNAP! 141 7F/
4. Connection to a public sewer is not feasible: /00 i-V.Ea,1C _%'WE2. I A) 7XL 4864
The Application for Local Upgrade Approval must be accompanied by all of the following:
(Check the appropriate boxes)
• Application for Disposal System Construction Permit
• Complete plans and specifications
• Site evaluation forms
❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines.
Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2).
❑ Other(List)
CERTIFICATION:
"I,the facility owner,certify under penalty of law that this document and all attachments,to the best
of my knowledge and belief,are true,accurate,and complete.f am aware that there may be
significant consequences for submitting false information,including,but not limited to,penalties or
fine and/or imprisonment for deliberate violations.
Facility owner's�signatuyre �1
Print name -(42UI4Aj )(AIM
-. , --egaPRSP Ale yr Date/0/2(70.)
Name ofpreparer R S]ff l-JAA)AS(6E mg_
Preparer's Address:/'/t -rn YLoP ,f r
City/Town: gas$Y State: ry7.4
Preparer's to ephone: ( '1/) ) t/6 7- 7.2zH
Date/0 /257 a a
Zip: D/o32
NOTE: 310 CMR 15.403(4)requires the system owner to provide a copy of the local upgrade
approval to the appropriate Regional Office of the Department of Environmental Protection,Bureau
of Resource Protection,Division of Watershed Management,upon issuance by the local approving
authority and before commencement of construction.
Department of Environmental Protection DEP Approved Form-320/02
Page 3 of 3
rvruvr yes •-
Commonwealth of Massachusetts
, Massachusetts
LOCAL UPGRADE APPROVAL SUED PURSUANT TO 310 CMR 15.404 & 15.405
Facility/system owner: Name: Address: to 5 a Address of facili ty S MP All1e -
Typc of facility: residential Y/.nstitutional commercial _ school _
design flow per 310 CMR 15103 gpd
4550e.site
Systcm designer: Name / Skeek&-Y1 Address /$16,7
g4g67
Ge-dt-at /MA
Loral Upgrade Approval granted for:
reduction in scrback(s) (specify)
60/P/4 7-
Phone 14.5. %%a'�
perc rate of 30-60 min./inch (specify rate)
_ reduction in SAS area of up to 25%
(specify % reduction&size of SAS)
reduction in separation between
SAS &high groundwater
(specify reduction&perc rate)
relocation of a well (explain)
List local variances granted (no DEP approval required per 310 CMR 15.412(4))
List variances granted requiring DEP approval ^/ /,, {�// J' / /[/o,rr
Board of Heal A Proval of po u e LP '�/�yG LrGr-ter- � '""
N &Title
i(/ ,(r //- 3-03
City/town Date
Si re
THE P RONAO VIR NL
TO THE A O RIATEREGIOLFF OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION
DIVISION OF WATER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL APPROVING AUTHORITY
& BEFORE COMMENCEMENT OF CONSTRUCTION.
DEP APPROVED FORM-12101/95